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Updated: May 17 2023

Genital Herpes in Pregnancy


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  • Snapshot
    • A 24-year-old G1P0 woman at 27 weeks gestation presents with painful lesions on her genitals. She denies any fevers, chills, or other flu-like symptoms. She reports that she has had ulcers in that area before that tested positive for HSV-2. She reports being concerned about transmission to her baby. She is started on acyclovir, which is a pregnancy category B medication.
  • Introduction
    • Overview
      • untreated genital herpes (most commonly herpes simplex virus-2) in pregnancy results in an increased risk of neonatal herpes simplex virus (HSV) infection
      • in a primary HSV infection, the transmission rate to the neonate is 50%
  • Epidemiology
    • Incidence
      • 5% of all women of childbearing age have a history of genital herpes
      • 22% of pregnant women are infected with HSV-2
    • Demographics
      • pregnant women
    • Risk factors
      • women
      • previous genital infection
      • number of sexual partners
    • Pathogenesis
      • mechanism
        • HSV is transmitted via direct contact with mucosa or disrupted skin
        • HSV transmission to the neonate occurs with passage of the neonate through the infected vaginal canal
  • Presentation
    • History
      • history of genital ulcers
    • Symptoms
      • common symptoms
        • may be asymptomatic
        • genital ulcers
    • Physical exam
      • inspection
        • tender erosions on external genitalia, vagina, or buttocks
  • Studies
    • Lesional studies
      • viral culture
      • polymerase chain reaction for HSV-1 and HSV-2
      • Tzanck smear
        • multinucleated epithelial giant cells
  • Differential
    • Varicella zoster virus infection
      • key distinguishing factor
        • rash is often more vesicular, with vesicles on an erythematous base that can become pustular
        • if reactivation of VZV, vesicles will group along a dermatome
  • Treatment
    • Delivery
      • vaginal delivery
        • if there are no active lesions
      • cesarean delivery
        • if there are active lesions, cesarean delivery should be performed within 4-6 hours of membrane rupture
    • Medical
      • acyclovir and valacyclovir
        • indications
          • all patients with active recurrent or primary genital herpes
          • pregnancy category B
  • Complications
    • Erythema multiforme
    • Disseminated HSV infection
    • Neonatal transmission
    • Eczema herpeticum
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